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Hirokazu Takami, Nikki Khoshnood, and Mark Bernstein


Awake surgery is becoming more standard and widely practiced for neurosurgical cases, including but not limited to brain tumors. The optimal selection of patients who can tolerate awake surgery remains a challenge. The authors performed an updated cohort study, with particular attention to preoperative clinical and imaging characteristics that may have an impact on the viability of awake craniotomy in individual patients.


The authors conducted a single-institution cohort study of 609 awake craniotomies performed in 562 patients. All craniotomies were performed by the same surgeon at Toronto Western Hospital during the period from 2006 to 2018. Analyses of preoperative clinical and imaging characteristics that may have an impact on the viability of awake craniotomy in individual patients were performed.


Twenty-one patients were recorded as having experienced intraoperative adverse events necessitating deeper sedation, which made the surgery no longer “awake.” In 2 of these patients, conversion to general anesthesia was performed. The adverse events included emotional intolerance of awake surgery (n = 13), air embolism (n = 3), generalized seizure (n = 4), and unexpected subarachnoid hemorrhage (n = 1). Preoperative cognitive decline, dysphasia, and low performance status, as indicated by the Karnofsky Performance Status (KPS) score, were significantly associated with emotional intolerance on univariate analysis. Only a preoperative KPS score < 70 was significantly associated with this event on multivariate analysis (p = 0.0057). Compared with patients who did not experience intraoperative adverse events, patients who did were more likely to undergo inpatient admission (p = 0.0004 for all cases; p = 0.0036 for cases originally planned as day surgery), longer hospital stay (p < 0.0001), and discharge to a location other than home (p = 0.032).


Preoperative physical status was found to be the most decisive factor in predicting whether patients can tolerate an awake craniotomy without complications, whereas older age and history of psychiatric treatment were not necessarily associated with adverse events. Patients who had intraoperative adverse events often had reduced chances of same-day discharge and discharge to home. Preoperative careful selection of patients who are most likely to tolerate the procedure is the key to success for awake surgery.